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If you would like a free General Liability Quote, please fill out the form below. If you have any questions, feel free to contact John Coggins at (850) 457-3299 or email him at jlcoggins@cogginsinsurance.com.
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The field marked with (*) are required fields.
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Full Name
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Phone Number
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Email Address:
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Name and Address of Business
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Type of Business
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Specific Duties In Job
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How many years of experience?
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How many employees?
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1
2
3
4
5-9
10-15
16-20
21 or more
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How many officers are in your business?
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1
2
3
4
5 or more
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How much is your payroll?
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What is the total of your Annual Receipts?
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Do you have any losses in the last 3 years?
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If there have been losses in the past 3 years, please list the amount and details?
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Who is your current insurance carrier?
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What is the expiration date of your current insurance?
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Have you had prior cancellations?
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Yes
No
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If prior cancellations, please list reason:
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What coverage amounts would you like for premises and operations?
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General Aggragate $100,000.00
General Aggragate $300,000.00
General Aggragate $500,000.00
General Aggragate $1,000,000.00
General Aggragate $2,000,000.00
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How much would you like for each occurance?
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$100,000.00
$300,000.00
$500,000.00
$1,000,000.00
$2,000,000.00
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How much coverage would you like for Damage to Rented Premises?
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$100,000.00
$300,000.00
$500,000.00
$1,000,000.00
$2,000,000.00
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Would you like coverage on Medical Payments at $10,000.00?
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Yes
No
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Who may we thank for referring you to our Agency?
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